Hospital Volume and Insurance Status Impact Complication Rates After Head & Neck Cancer Reconstruction
Leila Musavi, BA, Darya Fadavi, BS, Waverley He, BS, Justin Sacks, MD MBA, Oluseyi Aliu, MD.
Johns Hopkins School of Medicine, Baltimore, MD, USA.
PURPOSE: Head and neck cancer (HNCA) reconstruction is increasingly centralized at high-volume hospitals. However, a significant patient population receives surgical care at low-volume centers, and Medicaid patients comprise a disproportionate fraction of this population. Furthermore, Medicaid patients experience higher complications after a number of high-risk surgeries. Thus, we analyzed trends in HNCA reconstruction to evaluate the effects of hospital volume and insurance status on the rate of post-operative complications.
METHODS: With data from the National Inpatient Sample, we performed a cross-sectional analysis of patients undergoing HNCA resection from 1998-2015 using cross-tabulations and multivariate regression. The average number of HNCA ablative surgeries performed per year was stratified by tertiles to classify hospitals as low-, intermediate-, and high-volume. Rates of pedicle/free-flap reconstruction and post-operative complications were calculated for each year by hospital volume and insurance status. For multivariate analysis, in-hospital complications were examined as the dependent variable; age, race, sex, insurance status, comorbidities, prior radiation, hospital teaching status, and hospital volume were independent variables.
RESULTS: From 1998-2015, 284,107 patients underwent HNCA surgery; 57,293 received flap/pedicle reconstruction (20.2%). Cut-offs for tertiles of hospital volume were <25, 25-50, and >50 surgeries/year. High-volume hospitals performed over two times more reconstructions than low-volume hospitals. Reconstruction rates increased steadily over the study period (Figure 1). The annual growth in reconstruction rate was significantly higher in high-volume hospitals than low-volume hospitals (regression coefficients 1.42 and 0.74, respectively, p<0.01). Complication rates were consistently lower at high-volume centers (Figure 2). High-volume centers treated larger percentages of Medicare and privately-insured patients; low-volume centers, on the other hand, treated higher percentages of Medicaid patients in recent years (Figure 3). On multivariate regression analysis, Medicaid patients treated at low-volume centers had almost two times higher odds of complication than privately-insured patients (OR 1.74, p=0.026); this discrepancy was mitigated at high-volume centers, although it was still significant (OR 1.36, p=0.015).
CONCLUSIONS: The rate of increase in HNCA reconstruction is higher and the rate of complications lower in high-volume hospitals. High-volume hospitals are treating greater proportions of Medicare and privately-insured patients than Medicaid patients. Medicaid patients treated at low-volume hospitals have significantly higher odds of complication compared to private payers. While this difference is mitigated at high-volume hospitals, it is still significant. These results suggest that insurance status impacts HNCA reconstructive outcomes and that this relationship may manifest to different extents in low- vs. high-volume hospitals. Further investigation into additional outcomes variables, including length of stay and hospital charges, will help inform policies to mitigate these socioeconomic disparities.
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